Alaide Chieffo

Impact of drug-eluting stent selection on long-term clinical outcomes in patients treated for unprotected left main coronary artery disease: the sirolimus vs paclitaxel drug-eluting stent for left main registry (SP-DELFT).

AIM To compare the long-term relative efficacy and safety of SES and PES in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease and to evaluate the role of lesion location and stenting technique in determining outcomes. METHODS AND RESULTS From April 2002 to April 2004, 288 consecutive patients who underwent elective PCI with DES implantation for de novo lesions on ULMCA have been retrospectively selected and analyzed in seven European and US tertiary care centers. All patients had a minimum follow-up of 3 years. SES was used in 152 patients while 136 received PES. Isolated ostial-shaft disease was present in 27% of patients. Distal LM disease (73%) was treated with single and double stent approach in 29.5% and 43.4% of patients respectively. After 3 years, rates of survival free from any of the events investigated, were independent from lesion location and stenting approach and did not differ significantly between SES and PES groups. Freedom from MACE (SES vs. PES) was 76.3% vs. 83.1% in the ostial/shaft group, 80.3% vs. 72.8% in the distal-single stent group and 67.1% vs. 66.2% in the distal-double stent group. Definite stent thrombosis occurred only in 1(0.3%) patient at 439 days. CONCLUSIONS In elective patients who underwent PCI for de novo lesions in the ostium, shaft or distal ULMCA, long-term clinical outcomes with SES and PES use were similar independently of lesion location and stenting technique.

Diabetic patients treated for unprotected left main coronary artery disease with drug eluting stents: a 3-year clinical outcome study. The diabetes and drug eluting stent for LeFT main registry (D-DELFT).

AIMS Diabetes mellitus (DM) plays an important role in the development of coronary artery disease. Although previous studies have associated drug-eluting stent (DES) implantation in diabetic patients with favourable clinical and angiographic outcomes, the very long-term efficacy of these devices in diabetic patients undergoing PCI for significant unprotected left main coronary artery (ULMCA) disease has not been established yet. METHODS AND RESULTS Consecutive diabetic patients (n=100), who underwent elective PCI with DES for de novo lesions in an ULMCA between April 2002 and April 2004 in seven tertiary health care centres, were identified retrospectively and analysed. Consecutive non-diabetic patients (n=193), who underwent elective DES implantation for unprotected ULMCA disease, were selected as a control group. All patients were followed for at least 36 months. At 3-years follow-up, freedom from cardiac death & myocardial infarction (CDMI), target lesion revascularisation (TLR) and target vessel revascularisation (TVR) did not differ significantly between groups. The adjusted freedom from major adverse cardiac events (MACE, defined as the occurrence of CD, MI or TVR) was 63.4% in the DM group and 77.6% in the controls (p<0.001). When divided into IDDM and NIDDM sub-groups, insulin-dependent DM (IDDM) but not non IDDM (NIDDM) patients had significantly lower freedom from CDMI, TLR, TVR and MACE compared to controls. CONCLUSIONS These results suggest that major improvements in DES technology and pharmacotherapy are still required to improve clinical outcome and that the decision to perform percutaneous revascularisation in this subset of patients should be taken cautiously and on a case by case basis.

Bifurcations: Tips and Tricks

Coronary bifurcation lesions are a heterogeneous group which remain a challenge to the interventional cardiologist. Contemporary opinion is that the provisional T strategy is the preferred technique, however the side branch often has to be recrossed to allow an acceptable result. This chapter aims to look at some techniques which can be followed to enable the side branch to be accessed and treated. This includes methods during stent implantation in the main branch and also what the operator can do when the wire or balloon will not cross to allow a successful interventional result.

Technical Aspects of Left Main Stem Percutaneous Coronary Intervention

Significant (>50 %) unprotected left main stem disease (ULMS) is found in 5–7 % of all patients undergoing coronary angiography and is of prognostic importance by virtue of the large volume of myocardium that it supplies. With advances in technology, coupled with increased operator experience, percutaneous coronary intervention (PCI) of ULMS is not only feasible, but has been shown to be safe and effective in this patient group. Diagnosis with the use of angiography, intravascular imaging and coronary physiology indices to characterize LMS plaque and determine its functional significance is critical to planning the optimal percutaneous strategy. Based on anatomical considerations of the location of disease and branch anatomy, the appropriate stent strategy and equipment required can be selected. Lesion preparation is fundamental to optimal outcomes irrespective of which stenting strategy is decided upon. In general a single (provisional) strategy is preferred but in selected circumstances a 2-stent strategy should be used. Finally, post-stent implantation optimisation with intravascular imaging is mandatory to ensure the best possible outcome in addition to the correct adjunctive pharmacotherapy.